Provider Demographics
NPI:1154615227
Name:KETTER, COURTNEY
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:KETTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6905 DIVER AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-3103
Mailing Address - Country:US
Mailing Address - Phone:310-409-5882
Mailing Address - Fax:
Practice Address - Street 1:3455 W CRAIG RD STE C
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5119
Practice Address - Country:US
Practice Address - Phone:702-518-4337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1134362056Medicaid